Intake Form - Praktijk Vrije Geest

Theralogio

Intake Form - Complete all steps to begin your therapy journey

Progress

1Personal Info 2Address & ID 3Medical Info 4Preferences 5Review

Need help?

If you have questions about the intake form, please contact us.

Medical Information

Please provide information about your medical history and the reason for therapy.

Reason for Seeking Therapy *

Minimum 50 characters required

0/50 minimum

Medical History (Optional)

Current Medications (Optional)

Allergies (Optional)

General Practitioner (Optional)

We may contact your GP if medically necessary

Emergency Contact

Contact Name *

Contact Phone *

Your data is protected under GDPR and Belgian healthcare regulations.
Medical records are retained for 30 years as required by law.